Free musculocutaneous flap transfer for refractory chronic empyema with chest wall sinus in a 43-year-old male with hemophilia A

Salvage treatment of acute respiratory failure after autogenous tissue flap transplantation for chronic empyema with chest wall sinus: a case report and literature review

BACKGROUND

Chronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important.

CASE PRESENTATION

This paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation.

CONCLUSIONS

After a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

Pedicled myocutaneous flap transplantation for a large chest wall defect with infection in a 72-year-old female

Background

In the realm of thoracic surgery, addressing chest wall defects accompanied by infections remains a formidable task. Despite the availability of a spectrum of surgical options, attaining clinical resolution is particularly challenging in intricate cases involving extensive chest wall defects in elderly patients. Thorough debridement followed by the utilization of autologous tissue for repair and reconstruction has emerged as a prevalent approach in current clinical practice.

Case presentation

Herein, we present a 72-year-old female patient with a large chest wall defect and infection. She has experienced left breast cancer surgery, multi cycle radiotherapy and chemotherapy. Nine months ago, there was yellow purulent fluid in the left chest wall. She had undergone debridement in other hospital, and the treatment effect was poor. At our hospital, Chest computed tomography (CT) imaging revealed a soft tissue anomaly on the left side of the chest wall, along with partial rib bone deterioration. Considering the patient's clinical presentation and radiological findings, a tentative diagnosis of an infected chest wall defect and chronic osteomyelitis was established. Consequently, daily dressing changes were deemed necessary for the patient's infected chest wound. Surgery for chest wall repair and reconstruction was scheduled once the wound area exhibited cleanliness with emerging granulation tissue. Preoperatively, a myocutaneous flap of an appropriate size was meticulously planned. During the surgical procedure, initial debridement of the infected chest wall area was conducted, followed by the strategic placement of a harvested pedicled latissimus dorsi myocutaneous flap to rectify the defect. Postoperative care involved stringent anti-infective measures, anti-spasmodic treatment, and preventive anticoagulation, accompanied by vigilant monitoring of the myocutaneous flap's viability and the healing progress of the defect site.

Conclusions

Utilizing the pedicled latissimus dorsi myocutaneous flap for repairing extensive defects in the chest wall presents a viable and efficient strategy. This technique preserves cardiopulmonary functionality and maintains the thoracic contour. The outcomes observed in the short to medium term postoperatively have been consistently gratifying.

Autologous myocutaneous flap implantation for chronic refractory chest wall sinus with infection: a case report

BACKGROUND

Chest wall sinus with infection is a refractory disease caused by a variety of susceptible factors, and the treatment is still challenging. For clinically complex cases, although there are various surgical methods to choose from, it is still very difficult to achieve clinical cure, especially for patients with older age and many underlying diseases. Complete resection of chest wall sinus and application of repair and reconstruction technology may bring hope to refractory cases.

CASE PRESENTATION

Herein, we report a case of a 67 year-old woman who had undergone breast cancer surgery and a history of multiple cycles of radiotherapy and chemotherapy. One year ago, she had a fistula in the left chest wall with yellow purulent fluid. After admission to our hospital, chest computed tomography (CT) showed the formation of the left chest wall sinus, accompanied by high-density images of the left clavicle, part of the ribs and part of the sternu. According to the patient's symptoms, signs and imaging examination, we preliminarily diagnosed the patient as chest wall sinus with infection and chronic osteomyelitis. Therefore, in the first-stage operation, the patient underwent left chest wall sinus resection, left partial rib resection, left partial clavicular resection and left partial sternal resection, After surgery, the wound surface was changed with gauze dressing with sensitive antibiotic solution every day until the wound surface was clean and new granulation was formed. In the second-stage operation, the wound surface was appropriately expanded, and the pedicled latissimus dorsi myocutaneous flap was transferred to the chest wall defect. Finally, the skin paddle was sutured without tension to the normal skin around the chest, and two drainage tubes were placed. Anti-infection, anti-spasm, anti-coagulation and other treatments were given after operation, and the survival of myocutaneous flap, wound healing and sinus disappearance were observed.

CONCLUSION

The application of pedicled latissimus dorsi myocutaneous flap in the treatment of intractable chronic chest wall sinus is an effective method. It does not change the shape of the thorax. The clinical effect is satisfactory in the near and medium term, which is worthy of clinical promotion.

Preliminary experience of autologous free myocutaneous flap combined with free dermal graft in the treatment of refractory empyema with bronchopleural fistula

Objectives

To explore the effects of autologous free dermal graft combined with free myocutaneous flap on bronchopleural fistula (BPF) with empyema, we summarized and analyzed two cases.

Methods

Two patients with refractory empyema and BPF were treated with autologous free dermal graft combined with free myocutaneous flap. The treatment included debridement of empyema, rib resection drainage, repair of bronchopleural fistula, and free vastus lateralis myocutaneous flap transplantation to eliminate the empyema. After the free dermal graft was harvested from the healthy skin around the incision, it was inserted into the fistula and sutured with the surrounding pleural tissue. The keys to the operation lies in the anastomosis of the lateral circumflex femoral artery (LCFA), vein and nerve that supply the vastus lateralis muscle flap to the thoracodorsal vessels and nerves. After surgery, the empyema, air leakage, and the survival of the myocutaneous flap were observed.

Results

There was no disease recurrence after follow-up for seven and six months, respectively. Re-examination of the chest computed tomography (CT) or magnetic resonance imaging (MRI) indicated that the abscess cavity had disappeared. No necrosis of the myocutaneous flap was observed after surgery.

Conclusion

The application of autologous free dermal graft combined with free vastus lateralis myocutaneous flap transplantation is effective in the treatment of patients with bronchopleural fistula with refractory chronic empyema, and the clinical effect is satisfactory.

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Surgical treatment of refractory empyema.

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Autologous free dermal graft combined with free myocutaneous flap in the treatment of refractory bronchopleural fistula with empyema.

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Application of free myocutaneous flap in patients with empyema.

Limited thoracoplasty and free musculocutaneous flap transposition for postpneumonectomy empyema: A case report

BACKGROUND

Empyema is a severe complication following pneumonectomy that is associated with high morbidity and mortality rates. Although there are a wide variety of treatment options, successful management remains challenging when this condition is combined with a large cavity in very thin patients who had previously undergone a posterolateral thoracotomy.

CASE SUMMARY

We reported the case of a thin, 63-year-old man with a progressive pulmonary cyst who underwent left pneumonectomy via posterolateral thoracotomy 23 years ago. After an initially uneventful postoperative course, he was readmitted with empyema and a large cavity 21 years after surgery. He was successfully treated with limited thoracoplasty, followed by free vastus lateralis musculocutaneous flap transposition.

CONCLUSION

This case highlights that the treatment mode of limited thoracoplasty and free vastus lateralis musculocutaneous flap transposition is safe and effective for the management of postpneumonectomy empyema with a large cavity in thin patients who had previously undergone a posterolateral thoracotomy.

An 83-year-old-male with bronchopleural fistula and empyema successfully treated with multidisciplinary management of thoracostomy, endoscopic, and surgical treatment: a case report

Bronchopleural fistula (BPF) with empyema is a severe complication in patients undergoing lobectomy or pneumonectomy and is associated with high morbidity and mortality rates. Although a wide variety of treatment options exist, refractory cases with larger fistulas are still difficult to cure, especially in elderly patients. Here, we report a case of an 83-year-old man with stage I squamous cell lung carcinoma who underwent minimally invasive right lower lobectomy. After an initially uneventful postoperative course, he was readmitted to our hospital due to the progression of severe cough with fever after lung resection. Chest computed tomography (CT) showed an empyema cavity containing pleural effusion and a drainage tube in the right lower thorax. Bronchoscopy confirmed the presence of a fistula between the right lower bronchial stump and the pleural cavity. On the basis of his clinical symptoms and these imaging findings, the patient was diagnosed with BPF with empyema after lobectomy. He was successfully treated with multidisciplinary management including adequate pleural drainage by open-window thoracostomy, closure of the BPF by endoscopic therapy using an Amplatzer device, and complete obliteration of the empyema cavity with pedicled muscle flap. Multidisciplinary management combining thoracostomy, endoscopic therapy, and pedicled muscle flap transfer is a safe and effective treatment for elderly patients with larger fistulas and empyema.

Effective treatment of bronchopleural fistula with empyema by pedicled latissimus dorsi muscle flap transfer: Two case report

RATIONALE

Bronchopleural fistula (BPF) is a dreaded complication after lobectomy or pneumonectomy and is associated with high morbidity and mortality. Successful management remains challenging when this condition is combined with empyema, and the initial treatment is usually conservative and endoscopic, but operative intervention may be required in refractory cases.

PATIENT CONCERNS

Two patients diagnosed with BPF with empyema were selected to undergo surgery in our hospital because they could not be cured by conservative and endoscopic therapy for 1 or more years. One was a 70-year-old man who had a 1-year history of fever and cough after he received a minimally invasive right lower lobectomy for intermediate lung adenocarcinoma and chemotherapy 2 years ago; the other was a 73-year-old man who had a 2-year history of cough and fever after he underwent a minimally invasive right upper lobectomy for early lung adenocarcinoma 3 years earlier.

DIAGNOSIS

Both patients were diagnosed with BPF with empyema.

INTERVENTIONS

After receiving conservative and endoscopic therapies, both patients underwent pedicled latissimus dorsi muscle flap transfers for complete filling of the empyema cavity.

OUTCOMES

The patients recovered very well, with no recurrence of BPF and empyema during postoperative follow-up.

LESSONS

It is crucial to not only completely control infection and occlude BPFs, but also obliterate the empyema cavity. Thus, pedicled latissimus dorsi muscle flap transfer associated with conservative and endoscopic therapies for BPF with empyema is a useful treatment option, offering feasible and efficient management with promising results.

Free vastus lateralis musculocutaneous flap transfer for radiation-induced chest wall fistula combined with osteomyelitis: Two case report

RATIONALE

Chronic chest wall fistula is a refractory and agonizing disease that results from multiple predisposing etiologies, including radiation-induced damage. Successful management remains challenging when this condition is combined with osteomyelitis, and a limited number of reports have been published in the literature concerning this management.

PATIENT CONCERNS

Two Chronic chest wall fistula patients were selected to undergo surgery in our hospital because they could not be cured by conventional therapy for several years. One is a 74-year-old female who has received a right radical mastectomy and had radiation therapy 23 years ago; the other is a 59-year-old male who underwent a excision of thyroid cancer and had chemoradiation therapy 20 years earlier.

DIAGNOSIS

Both patients were diagnosed with radiation-induced chest wall fistula combined with osteomyelitis.

INTERVENTIONS

After total resection of the diseased chest walls, both patients underwent free vastus lateralis musculocutaneous flap transfers, in which the vessels were microvascularly anastomosed to the transverse carotid artery and vein via a subcutaneous tunnel or a direct incision. Histologic evaluations of the specimens demonstrated inflammation and osteomyelitis.

OUTCOMES

The patients recovered very well and currently have no recurrence of chest wall fistulae during the postoperative follow-up.

LESSONS

It is crucial to not only completely resect chest wall fistulae and the surrounding diseased tissues but also reconstruct the chest wall. Thus, the use of the free vastus lateralis musculocutaneous flap transfer method for radiation-induced chest wall fistulae, combined with osteomyelitis, is a useful option for treatment and is also a feasible and efficient surgical procedure with promising results.